Reaching varied cultural groups requires education of staff, community

Understand differences and language to expand services

Only one in five hospice patients in 2009 were non-Caucasian, according to the 2009 NHPCO Facts and Figures: Hospice Care in America1 report issued by the National Hospice and Palliative Care Organization (NHPCO). This compares to U.S. Census data that show almost 25% of the U.S. Population as non-Caucasian.2 Hospices are looking for ways to reach diverse cultures and races to increase the number of patients who benefit from hospice at the end of life.

"The major challenge to reaching people of different cultures is that each group has different beliefs regarding end-of-life care," says Dale Knee, MHCA, president and CEO of Covenant Hospice in Pensacola, FL. These different beliefs include the use of pain medication, he says. "Even among Caucasians, some religious beliefs do not allow the use of pain medication to the point that the patient is unaware of his or her surroundings," Knee says. One American Indian tribe in Knee's service area believes that the stoic acceptance of pain is part of maintaining one's dignity while facing death.

Respecting religious and cultural beliefs is a critical part of providing hospice care and requires ongoing staff education, he says. "We train all of our staff, including admissions and outreach education staff members, to be sensitive to different views so we don't unknowingly put up barriers or play on fears," Knee explains.

For example, the largest minority population in his hospice service area is African American. Because some African Americans are concerned about the disparity of health outcomes between their community and others, they often view a referral to hospice as the medical profession giving up on their family member, according to Duke University researchers.3 For this reason, reassure family members and patients of the benefits of hospice care such as better pain control, says Knee. "Explain that no one is giving up on the patient; it is just a change in the methods of providing care," he says.

Cultural diversity training is required for all staff members, says Knee.

"They must complete the inservice training within 90 days of being hired, and they take refresher courses annually," he explains.

Courses can be taken through computer-based modules offered by the agency or by attending inservices at which speakers are invited, Knee says. "Fifteen years ago, we were bringing in a lot of speakers to talk about different cultural, religious, or ethnic groups, but today we rely more on the modules," he says. "When we hear from staff members that they are seeing patients that practice a religion we don't typically see or a cultural group that is new to the area, we find a member of that community who can present an inservice."

Staff members at New Life Hospice in Elyria, OH, have two in-house experts to provide education related to the Latino community in their service area, says Joan Hanson, RN, BSN, director of the agency. A Latino nurse and aide not only serve as staff education experts, but they also conduct community outreach by speaking to Latino groups.

Outreach efforts at Covenant Hospice involve different cultures and are focused, says Knee. "We cover 35 counties that represent several different cultural populations," he says. The agency has developed a computer model that analyzes the number of patients from each zip code, says Knee. "When we see a drop in a zip code that represents a specific cultural group, we increase community education efforts in that area," he says.

The best way to reach out to the community is through organizations that are important to the group you are trying to reach, points out Knee. "Churches are very important in the African American community, so we not only offer presentations at churches, but we try to identify staff members or volunteers who attend the church to be part of the presentation," he says. "Churches and cultural centers are also important in the Vietnamese and Greek communities in our area."

In addition to cultural beliefs, language also can be a barrier to reaching patients for whom English is not a first language, admits Knee. A combination of staff members who speak different languages, interpreter services from a local university, and educational material printed in different languages help the hospice staff communicate with patients, he points out.

One of the trickiest parts of honoring patient and family cultural beliefs is to balance their beliefs, your staff assignments, and the avoidance of discrimination, Knee says. Some cultures are specific about whether or not a male can care for a female or vice versa, he says. "We identify these requests at admissions and try to accommodate the family's wishes," Knee says. "It is especially important to identify requests that differ due to culture regarding activities after death."

Communicate openly and honestly with staff members, and point out the need to honor the patient's wishes, Knee says. "We have to recognize that a patient's beliefs may not be the same as ours and adapt to the situation," he says. "After all, our primary goal is to provide the best end-of-life care for the patient and family, and that includes honoring their cultural or religious beliefs."


1. National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA; 2009.

2. U.S. Census Bureau. Data Set: 2008 American Community Survey 1-Year Estimates; Survey: American Community Survey; 2007.

3. Payne R, London G, Latson S, et al. Key Topics on End-of-Life Care for African Americans. Duke Institute on Care at the End of Life, Durham, NC; 2006.

Need More Information?

For more information about programs to reach diverse populations, contact:

• Joan Hanson, RN, BSN, Director, New Life Hospice, 5255 N. Abbe Road, Elyria, OH 44035. Phone: (440) 934-1458.

• Dale Knee, MHCA, President and Chief Executive Officer, Covenant Hospice, 5041 N. 12th Ave., Pensacola, FL 32504. Phone: (850) 433-2155.

• The Joint Commission offers tools and publications to help health care organizations identify best practices to meet the needs of diverse patient populations. The publications include One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations, a research report that includes a self-assessment tool that hospices can use to evaluate their diversity programs. To download a free copy of the report, go to On the top navigational bar, select the "patient safety" button, then select "hospitals, language and culture." Scroll down the page to the publication title.

• The National Hospice and Palliative Care Organization offers to reach patients of different cultures on its Caring Connections web site. Go to, select "Are you reaching your community" and scroll down to "Diversity outreach." Presentation and publications, including patient education material, specific to African American, Latino, and Chinese communities are available for free download.

• DiversityRX provides articles, descriptions of models and practices, and resources such as learning groups and other networking opportunities that can help hospices build a diversity program. Go to